NeighborImpact Energy Assistance Landlord Verification

NeighborImpact Energy Assistance Landlord Verification
For applicants whose utility bill is in the landlord’s name. Applicant is to have the landlord complete this form.

DO NOT COMPLETE IF YOUR UTILITY BILL IS IN A HOUSEHOLD MEMBER'S NAME
Applicant Name

First NameLast Name
Applicant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

For the Landlord